South West London 5 Year Strategic Plan South West London Collaborative Commissioning

Transcription

1 South West London 5 Year Strategic Plan South West London 5 Year Strategic Plan 20 th June 2014

2 South West London 5 Year Strategic Plan Table of Contents Chapter 1: Introduction... 1 Chapter 2: Vision... 7 Chapter 3: Case for Change... 9 Chapter 4: Clinical workstreams...41 Section 1: Children s services...43 Section 2: Integrated care...69 Section 3: Maternity care Section 4: Mental health Section 5: Planned care Section 6: Transforming primary care Section 7: Urgent and emergency care Section 8: Cancer care Chapter 5: Sustainability Chapter 6: How we will work together Chapter 7: Governance Appendices: Appendices Appendix 1: Children s services Appendix 2: Integrated Care Appendix 3: Performance against NHS Outcomes Framework Domains...289

3 Chapter 1: Introduction Chapter 1: Introduction 5 Year Strategic Plan 20 th June

4 Chapter 1: Introduction Contents Introduction from south west London CCG Chairs

5 Chapter 1: Introduction Introduction from south west London CCG Chairs Working together to improve the quality of care in south west London As GP leaders of new commissioning organisations getting to grips with the challenges facing local health services, it has become increasingly clear over the last year that we are facing a potential crisis. Whilst our budgets have not been reduced in real terms, rising demand from an ageing population and the costs of new technologies and drugs mean we have to address a gap of around 210m a year by the end of 2018/19. Sustaining existing levels of access and quality in this context is increasingly difficult both for us as commissioners and for local providers such as hospitals, GPs and mental health Trusts. However, we are adamant that quality needs to improve as referenced in the case for change chapter, services are not meeting minimum quality standards and when benchmarked against national and international evidence, are falling well short of where we think they should be. This presents us with a dilemma; either we can oversee a continuous decline in our local health system followed by organisational failure and a need for external intervention, or we work with clinical colleagues and local people to agree a planned set of changes that deliver the care that our residents deserve within the funding available to us in south west London. As the custodians of the health system, and as local GPs, we believe the latter is the only acceptable way forward. We will work with other clinicians in the local health system, our local authority partners and local people over the coming months to look at what some of these changes might be. Our services are inter-dependent and the challenges we face cross borough boundaries. We need closer working between our hospitals and also between the hospitals, GPs, community and mental health services if we are to improve quality for everyone in south west London and make the local NHS sustainable. We do not believe it would be possible to achieve the scale of change that is needed by working independently at borough level. We will work with our Local Authorities, Health and Wellbeing Boards, mental health trusts, primary and community care providers, local hospitals, patients and neighbouring Clinical Commissioning Groups (CCGs) to achieve substantial and lasting improvements in our health services. We unanimously support the south west London case for change, reinforced nationally by NHS England s Call to Action 1. If we do not address these challenges, we know that local services will decline in quality and that we will not be able to meet the required quality and safety standards. Our CCG governing bodies and NHS England (direct commissioning), who commission primary care and specialist services in south west London, have agreed to work jointly to develop new strategies for local health services. This includes this 5 year strategic plan for south west London. We remain committed to improving our hospitals We agree that all future hospital services should be commissioned against the London Quality Standards which are minimum safety standards developed by senior clinicians, based on the 1 Everyone Counts: Planning for patients 2014/15 to 2018/19, NHS England, 2013, London 3

6 Chapter 1: Introduction guidance of Royal Colleges and other equivalent bodies and that all hospitals must provide sevenday services which are not only consultant-led, but largely consultant delivered. We know this will not be easy as there are not enough senior and experienced doctors to fulfil these roles, and so the hospitals will have to work together to achieve this. We also expect our hospitals to comply fully with the recommendations set out in the national review of urgent and emergency care by Sir Bruce Keogh 2 and to be financially sustainable. As commissioners of primary care and specialist services in south west London, NHS England (direct commissioning) will work with us as part of a south west London strategic planning group to develop long term, sustainable improvements for patients. This collective work, and the work undertaken by a range of groups described in the governance chapter (7), will be overseen by the Strategic Commissioning Board. Our 5 year strategic plan includes bold ambitions for improving community, GP, mental health and specialist services We have listened to feedback from local people and we agree that we should look at local health services in a holistic way. Our draft strategic plan is structured as follows: Chapter 2: Vision sets out the vision for the strategy Chapter 3: Case for Change sets out the context and arguments for the proposed changes in the document Chapter 4: The clinical strategy for south west London setting out, by pathway, the interventions which CCGs will put in place over the five years of the strategy. The pathways discussed are as follows: o Children s services o Integrated care o Maternity care o Mental health o Urgent and unscheduled care o Primary care transformation o Planned care o Cancer care Chapter 5: Sustainability which describes how we will work to ensure services in 2018/19 are clinically and financially viable Chapter 6: How we will work together detailing how we work with our partners and engage with a broad range of stakeholders, both in developing and implementing the strategic plan Chapter 7: Governance setting out the structures we have put in place which oversee the development and delivery of the strategy 2 High quality care for all, now and for future generations: Transforming urgent and emergency care services in England Urgent and emergency care review End of Phase 1 report, NHS England, 2013, London 4

7 Chapter 1: Introduction The 5 year strategic plan is closely mapped to the 2-year and Better Care Fund plans The 5 year strategic plan sets the direction of travel for health services across south west London. We have deliberately separated out the objectives for years 1-2 of the plan from those to be delivered in years 3-5, in order to demonstrate the close tie between each CCG s 2 year operational plan and the themes identified in this document. The strategic plan does not include any detail of the range of interventions taking place in each borough, for this information please consult each CCG s individual plans, however the themes align closely across all six boroughs. In addition the Better Care Fund plans, developed jointly by CCGs and local authorities, give the full detail of the interventions planned in 2014/15 and 2015/16 to transform integrated services in the community. The major themes from this work are captured in the Integrated Care section of this strategy. We are committed to working with local providers, patients and the public We are committed to working with local providers, service users and the public to develop solutions that will deliver safe, high quality care for everyone. Much public engagement was carried out prior to the establishment of and we have continued to listen to a wide range of stakeholders when developing the 5 year strategic plan. There have been many separate engagement events, culminating in a large meeting on the 8 th May to gather views from a wide range of local organisations and patient representatives. Should the outcome of our discussions mean major service change at any of our hospitals which we think is likely, given the difficulty of meeting the London Quality Standards across four hospitals then proposals would, of course, be subject to public consultation. As commissioners of health and care services in south west London we are committed to working together to improve the quality of care for our residents. 5

8 Chapter 1: Introduction 6

9 Chapter 2: Vision Chapter 2: Vision 5 Year Strategic Plan 20 th June

10 Chapter 2: Vision Vision The overarching vision for the south west London 5 year strategic plan People in south west London can access the right health services when and where they need them. Care is delivered by a suitably trained and experienced workforce, in the most appropriate setting with a positive experience for patients. Services are patient centred and integrated with social care, focus on health promotion and encourage people to take ownership of their health. Services are high quality but also affordable. Each of the clinical workstreams in Chapter 4 presents its own vision for what care will be like and how it will be delivered in 2018/19 for the affected section of the population in south west London. 8

11 Chapter 3: Case for Change Chapter 3: Case for Change 5 Year Strategic Plan 20 th June

12 Chapter 3: Case for Change Contents 1. Health services in south west London must be responsive to issues facing the whole NHS Key drivers for change Key driver 1: We need to improve the quality of care across south west London Key Driver 2: We need to tackle the workforce gap Key driver 3: We need to ensure local NHS services are financially sustainable...18 Key driver 4: We need to confront the rising demand for healthcare Population health and inequalities Local performance against the seven measurable outcomes Outcome 1: Securing additional years of life for the people of England with treatable mental and physical health conditions Population and life expectancy data for south west London Leading causes of death Lifestyle issues Summary and strategic objectives Outcome 2: Improving the health related quality of life of the 15million+ people with one or more long-term conditions, including mental health conditions Prominent Long-Term Conditions Quality of Life Indicators Summary and strategic objectives Outcome 3: Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital People are being treated in a hospital setting where they could be more appropriately treated in alternative settings Community services and primary care Summary and strategic objectives Outcome 4: Increasing the proportion of older people living independently at home following discharge from hospital The elderly population Admissions to Residential/Nursing Care Summary and strategic objectives

13 Chapter 3: Case for Change Outcome 5: Increasing the number of people with mental and physical health conditions having a positive experience of hospital care Summary and strategic objectives Outcome 6: Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital, in general practice and in the community Summary and strategic objectives Outcome 7: Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care Summary and strategic objectives Conclusion

14 Chapter 3: Case for Change 1. Health services in south west London must be responsive to issues facing the whole NHS There is a broad consensus among doctors and nurses both nationally and locally that the NHS needs to change. NHS England s A Call to Action highlights the clinical, financial and logistical challenges faced across the country and requires local commissioners to put forward plans to tackle these. The NHS must respond to new challenges, such as increasingly more complex needs and higher expectations of quality, alongside more long-standing challenges such as rising demand, financial balance and the availability of sufficient, suitably skilled staff. We need to celebrate what is already working well whilst being honest about the issues the NHS is facing. Despite progress across all settings, current services are inconsistent, do not meet the recommended safety and quality standards and are not financially sustainable. Clinicians from south west London, alongside patients, have led the way in designing clinical standards, yet these standards are not currently being achieved in full across our hospitals. Whilst these standards are ambitious they represent the minimum, not the maximum, level of clinical quality we, and our patients, expect. We need to ensure patients receive this standard of care at a time when NHS funding is not increasing as quickly as its costs. Each year, NHS organisations will have to find efficiency savings just to deliver the same level of service. For south west London clinical commissioning groups (CCGs) there is a forecast do nothing savings challenge of approximately 210m by 2018/19 to achieve a 1% surplus. All change brings a degree of uncertainty, and change in the NHS is particularly unsettling for many stakeholders. As clinically led organisations, we are clear that: we are not currently receiving the quality of care we want from our hospitals we cannot deliver care to the quality that we want without changing the way in which services are provided in south west London we face a significant financial challenge today and, without change, this will become far worse in the future. An important consideration for our 5 year strategic plan is ensuring local commissioners treat mental health and physical health services with a parity of esteem, under which all organisations need to assign the same priority to the development of mental health services as physical health services. As ever it is important to understand the local context when considering any change and this chapter sets out specific challenges faced in south west London. Whilst the CCGs have decided to work together with NHS England as a strategic planning unit, much of the individual work taking place in each borough will continue to be led by local organisations. This case for change will focus on the broader trends which the five-year strategic plan needs to address, rather than on some of the individual problems CCGs are tackling, which will be addressed in CCG specific plans. 12

15 Chapter 3: Case for Change In light of the challenges we face, south west London has been selected as one of eleven challenged health economies that will receive support with strategic planning in order to secure sustainable quality services. We are now working with PwC, who are providing intensive support to our strategic planning. The case for change outlines where performance needs to be improved across the health system, setting out our four key drivers of change. We then discuss our progress against the seven measurable outcomes identified by NHS England. These outcomes give us a framework around which to identify and develop the interventions which will be explained later in the five-year strategic plan. 2. Key drivers for change There are four key drivers for change in south west London that must be addressed, namely: the quality of care the workforce gap financial sustainable rising demand for healthcare. Key driver 1: We need to improve the quality of care across south west London There is clear clinical consensus around the quality of care that all acute hospitals need to achieve, represented by the Seven Day Working Clinical Standards and London Quality Standards The Royal Colleges develop clinical guidelines across their respective specialisms in order to help hospitals achieve the highest quality care for patients and make best use of the workforce. Existing guidelines reinforce the need to deliver high quality care throughout the day and week, and in London clinicians have worked together to develop a set of standards which builds on Royal College guidance 1 and details the minimum safety standards patients should expect when they are treated in hospital. These standards are called the London Quality Standards (LQS). They were developed following the review of adult emergency services undertaken by the London Health Programmes (LHP) in 2011 on behalf of London s commissioners, highlighting the variability in quality of hospital-based acute medicine and emergency surgery in London. The LQS are based on clinical evidence, national recommendations and best practice, and their development involved a group of over 90 clinicians that formed multi-disciplinary expert panels, service user and public groups. They have also been endorsed by the London Clinical Senate and the London-wide Clinical Commissioning Council. 1 Academy of Royal Colleges (2013) Changing Care Improving Quality Reframing the debate on reconfiguration 13

16 Chapter 3: Case for Change Clinical commissioning groups (CCGs) in south west London have made a firm commitment to achieving LQS across emergency, maternity and children s services. London is not alone in requiring higher standards of quality for patients and the aims of local clinicians have been underpinned by national guidance that has arisen following Professor Sir Bruce Keogh s (NHS Medical Director) review into urgent care services across the country. The NHS Services Seven Days a Week Forum, which was established as part of this review, reported in December 2013 that it had established 10 Clinical Standards for seven day working 2. These standards are broader in scope than the London Quality Standards, applying to all NHS services rather than just acute services, but set out a minimum level of service which patients can expect to receive wherever and whenever they fall ill. The standards require: Prompt access to consultant review and multi-disciplinary assessment Availability of diagnostics to support decision-making A focus on mental health diagnosis and treatment Planned, safe and appropriate timing of discharges The availability of support services in primary and community care to ensure that a patient receives joined up care across all services In December 2013, the Forum confirmed that it would require its seven-day working standards to be implemented by 2015/16. These form a significant part of the case for change in south west London and the achievement of seven day working will be an important step on the way to CCGs ultimate objective of having LQS in place across all hospital sites. Currently some community services are not available seven days a week, and the appropriate processes and support systems are not in place to ensure patients can be safely discharged over the weekend. Evidence shows that patients are currently more likely to have negative health outcomes if they fall ill at the weekend Providing a consistent standard of service throughout the week is a national priority for the NHS. Some specialised services have already moved to providing high quality, consultant-delivered care seven days a week, with demonstrable benefits to patient outcomes and service efficiency, however the majority of care is provided over a five-day working week. Whilst health services scale down for the weekend, the urgent and emergency needs of patients do not. The detrimental effect of not having senior staff to make timely, accurate decisions, as well as the other vital health professionals and support services that all play a part in caring for patients, is clear. For example evidence shows people admitted to hospital as an emergency at the weekend are 10% more likely to die compared to patients admitted on a weekday 3. This equates to approximately 420 lives in London that could be saved each year if the mortality rate for patients 2 NHS England (Dec 2013) NHS Services, Seven Days a Week Forum: Summary of Initial Findings 3 Ayling et al (2010) Weekend mortality for emergency admissions A large multicentre study Quality and Safety in Health Care, 19:

17 Chapter 3: Case for Change admitted as an emergency at the weekend was reduced to the level seen for those admitted on weekdays 4. The importance of seven-day working for good patient outcomes is highlighted through other reviews. For example, according to research by University of Cambridge 5 on neonatal deaths in Scotland, there is a higher risk of death when a baby is delivered outside of normal working hours. We need to ensure that patients have access to the same level of specialist treatment whenever they require care. Progress to date in achieving London Quality Standards London hospitals were audited against the adult emergency medicine and emergency surgery standards in 2012/13, and analysis of the audit results shows that the four hospitals altogether met only half of the 49 emergency medicine and surgery standards 6. Notably, none of the hospitals was meeting the following standards: All emergency surgical admissions to be seen and assessed by a relevant consultant within 12 hours of the decision to admit or within 14 hours of the time of arrival at the hospital All patients on acute medical and surgical units to be seen and reviewed by a consultant during twice daily ward rounds, including all acutely ill patients directly transferred, or others who deteriorate Prompt screening of all complex-needs inpatients to take place by a multi-professional team which has access to pharmacy and therapy services, including physiotherapy and occupational therapy, seven days a week with an overnight rota for respiratory physiotherapy. The tables below summarise the findings from the LQS audit of emergency standards: Adult Emergency Services Croydon Epsom St Helier Kingston St George's Audit Standard Medicine Surgery Medicine Surgery Medicine Surgery Medicine Surgery Medicine Surgery Met N/A Not Met N/A Table 1: Results from the self-assessment of trusts against the adult emergency standards 2013 Paediatric Services Croydon Epsom St Helier Kingston St George's Audit Standard Medicine Surgery Medicine Surgery Medicine Surgery Medicine Surgery Medicine Surgery Met N/A Not Met N/A Table 2: Results from the self-assessment of trusts against the paediatric emergency standards Urgent and Emergency Care Review Team (2013) Transforming Urgent Care and Services in England Urgent and Emergency Care Review 5 Pasupathy et al(2010) Time of birth and risk of neonatal death at term : retrospective cohort study 6 London Health Programme, Quality and Safety Programme: Audit of Acute Hospitals for St George s, Kingston, Croydon and St Helier (May 2012-January 2013) 15

18 Chapter 3: Case for Change Maternity Croydon Epsom St Helier Kingston St George's Audit Standards Met Not Met Table 3: Results from the self-assessment of trusts against the maternity standards 2013 These results show that we are currently meeting an average of 67% of the adult emergency standards, 77% of paediatric standards and 85% of maternity standards 7. However, there are a few examples of standards that are not being met by any of the trusts in south west London. These include 168-hour consultant obstetric presence on labour wards, twice daily ward rounds in both adult medicine and surgery and the prompt screening of all complex needs patients by a multiprofessional team with a clear multi-disciplinary plan in place within 14 hours. We know that we cannot meet full LQS across our hospitals without making changes to the way current services are delivered. The main reason for this is that there not enough consultants to deliver the level of cover required. Key standards determined by local clinicians include: All A&Es should establish sufficient emergency medicine consultant numbers to provide 16 hours a day, seven days a week consultant presence as a minimum 8,9 The clinical team on the AMU should be consultant led. This will typically require on average one consultant per 25 admissions per day or less. There should be a twice-daily consultantled ward round/review of all patients in the AMU, seven days a week There should be sufficient emergency surgeons to be present 12 hours a day, seven days a week There should be 24/7 cover of consultant anaesthetists, who should be available to be on site within 30 minutes, seven days a week All obstetric units should be staffed to provide 168 hours (24 hours a day, seven days a week) obstetric consultant cover, regardless of the number of births All children s wards should have paediatric consultant cover for 14 hours a day, seven days a week Paediatric consultant-led 24/7 Children s Short Stay Units (CSSUs) should be developed on all sites that provide A&E care for children, with at least 14-hour paediatric consultant presence. Against reported consultant numbers in January 2013 it was calculated that in order to meet the agreed standards across all four hospital sites in south west London over 180 more consultants would be required by 2017/18 (see table below for breakdown). It should be noted that this calculation covered six specialties only, and did not take into account support services such as radiology or clinical pathology. 7 It should be noted that for those standards that were reported as being met during the week but not at the weekend, we have recorded this as not being met. 8 London Health Programmes.Quality and Safety programme emergency departments.case for Change (February 2013) 9 The College of Emergency Medicine (2011) The Emergency Medicine Operational Handbook (The Way Ahead) 16

19 Chapter 3: Case for Change A&E Consultant shortfall to meet 112 hour cover in 2017/18 Obstetrician shortfall to meet 168 cover in 2017/18 Paediatricia n shortfall to achieve 98 hours a week cover in 2017/18 Emergency medicine consultant shortfall to meet standards in 2017/18 Emergency surgery shortfall to achieve 12/7 cover in 2017/18 Anaesthetist consultant shortfall to meet LQS in 2017/18 Total predicted consultant shortfall in 2017/18 Croydon Kingston St George s St Helier Total Key Driver 2: We need to tackle the workforce gap It is not possible to address the shortfalls described above simply by hiring more consultants, even if the funding were available. There is a limited supply of suitable staff nationally, and even if the hospitals could recruit sufficient staff to provide appropriate levels of clinical cover, the volume of activity at each hospital will not be high enough to allow doctors and other healthcare professionals to train and retain their skills. This means that merely hiring more staff is neither a workable nor sustainable solution to raising clinical standards. Because of difficulties in recruitment, progress towards seven-day working has been piecemeal and out-of-hours cover remains particularly fragile 10. Owing to a reduction in training numbers, the European Working Time Directive (EWTD) and increasing sub-specialisation, hospitals are finding it increasingly difficult to appropriately staff on-call rotas 11. In some hospitals there are unacceptably high levels of locum use, which gives rise to concerns about safety and value for money. For maternity services particularly, achieving a 168 hour consultant presence will be challenging, as the current consultant workforce would need to be significantly expanded. The Royal College of Obstetricians and Gynaecologists (RCOG) estimated that the current UK consultant obstetric workforce will need to increase from the present level of 1,500 to approximately 2,500 to deliver 168-hour cover in each of the 43 units in In south west London the Maternity and Newborn Clinical Working Group noted that there will be several key challenges to meeting the standard: Attracting and retaining the size of workforce required to deliver this level of cover The additional problems caused by the need to develop EWTD-compliant rotas The loss of junior medical training places, with around 30% of training posts estimated to disappear over the next five years A loss of junior medical training places, leading to a need for more consultant-delivered care 10 London Health Programmes Adult Emergency Services: Acute Medicine and Emergency General Surgery. NHS London. September Urgent and Emergency Care Clinical Working Group Final Clinical Report, London: NHS South West London, March 2012 p Maternity and Newborn Clinical Working Group Final Clinical Report, London: NHS South West London, March 2012, p

20 Chapter 3: Case for Change The financial affordability of significantly increasing consultant numbers 13 For children s services, the Royal College of Paediatrics and Child Health (RCPCH) has emphasised that nationally there is an overall shortfall in consultant paediatricians, and warned that as a consequence some paediatric units may have to close. 14 Given that there is not an inexhaustible number of trained paediatric doctors and nurses, there is now a limit to how many units can be staffed safely. There may also be shortages in trained health professionals in some other areas of practice. The number of doctors in training is expected to fall after growth in recent years and there are already shortages in some areas of nursing (e.g. an additional 37 WTE midwives are required to provide oneto-one care for women in labour). 15 Additionally Croydon, Epsom and St Helier and Kingston each have a shortfall of five interventional radiologists needed to meet LQS. 16 Unless we address these workforce problems in a comprehensive way, we will never be able to deliver the minimum safety standards required by our clinicians. Key driver 3: We need to ensure local NHS services are financially sustainable Over the next five years clinical commissioning groups, which hold the budgets that pay for the majority of community and hospital services, will face increasing financial pressure, in turn raising the chances of providers suffering a deterioration in clinical quality and safety. The NHS budget is expected to rise only in line with inflation during this time, and potentially for considerably longer. Spending, however, is expected to rise significantly over and above inflation, assuming CCGs continue to fund the same kind of services as they do today. There are many reasons why spending is expected to increase rapidly: The profile of the population is changing, with a larger number of older people, many of whom will suffer from long term conditions (LTCs). LTCs require long-term treatment, and not just in hospital but in primary and community settings also, and this treatment costs money A variety of public health trends are adding new pressures on the health system, with patients developing conditions such as diabetes and heart disease owing to obesity and other lifestyle factors There is a trend of rising hospital activity across a range of services from A&E attendances to out-patient appointments. Hospitals are expensive places to provide care compared with other care settings 13 Maternity and Newborn Clinical Working Group Final Clinical Report, London: NHS South West London, March 2012, p Royal College of Paediatrics and Child Health (2013) Facing the Future: Standards for Paediatric Services. 15 The case for change for health services in South West London, NHS South West London, October 2011, p London Health Programme (2012) Audit of Acute Hospitals 18

21 Chapter 3: Case for Change New drugs and technologies are constantly becoming available to the NHS, and these are often expensive to introduce and require upfront investment Ageing estate has to be modernised to ensure it is fit for purpose in the 21 st century. Taken together these challenges are expected to lead to an annual savings requirement for CCGs in 2018/19 of 10.2% 17 of expenditure. This means that every year we need to find new ways of delivering care whilst still meeting the high expectations of patients, and the minimum safety standards set by local clinicians. Taken together these pressures mean CCGs have to find 210m of savings over the next five years. The chart below shows that, without any improvements in productivity, commissioners would be faced with a gap of 210m 18 in 2018/19 to meet the 1% surplus requirement. ( 'million) 2,100 2, ,064 1,933 1,900 1,873 1, ,700 1,600 1,500 1,400 Total Programme Resources Commissioning Services Other Programme (incl. Reserves) Running Costs Contingency Total Expenditure (pre-qipp) In-Year Challenge to 1% South west London CCGs income and expenditure in 2018/19 The total savings target for the six CCGs, known as the QIPP (Quality, Innovation, Productivity and Prevention) challenge, can be addressed in a number of ways. Savings can be made through more appropriate prescribing of medicines for example, or through incentivising improvements in the productivity of existing contracts. CCGs are committed to achieving significant savings through transforming care out of hospital, thereby changing the balance of where care is delivered, creating a better experience for patients and improving integration of services. Savings in acute services 17 The gap is the calculated do nothing in-year challenge to meet the 1% surplus requirement in 2018/19 if CCGs delivered none of the planned QIPP schemes between 2014/15 and 2018/19. The calculation excludes return of previous year surplus / (deficits). Source: South west London CCG Commissioning Model (0 30) (based on CCG submissions to NHS England, 20 June 2014) 18 South west London CCG Commissioning Model (0 30) (based on CCG submissions to NHS England, 20 June 2014) 19

22 Chapter 3: Case for Change account for million of the planned QIPP savings over the five years, representing 67% of total net savings. This local drive is assisted by the national mandate to create a Better Care Fund (BCF), a joint health and social care fund which comes into effect in 2014/15 and then is fully implemented in 2015/16. As outlined in the letter from Sir David Nicholson to commissioners in October 2013, the BCF is a game changer for both commissioners and providers. The ring-fenced budget for investment in out-of-hospital care requires at a national level 2 billion of savings from existing spending in acute services. 19 In South West London, patient flows to acute providers cut across a number of CCGs, and commissioners recognise the need to work collaboratively to understand the activity and financial implications for acute service providers over the five year planning timeframe. The BCF is intended to be a significant enabler in the integration of care across providers. South west London CCGs will transfer a minimum of 85 million to the BCF in 2015/ It is important to understand that any change to the money CCGs spend on hospital services has a direct effect on the income of the hospital, and adds further pressure to the hospitals own savings targets. The impact of CCG transformation programmes will mean some providers will face increasing financial pressure The impact of QIPP, including the transformative change enabled by the BCF, is a catalyst for far reaching change across the NHS in south west London. Acute, mental health and community providers need to find savings over the next five years, however owing to the delivery of more care in primary and community settings and less care in hospital settings, these challenges will be particularly significant for acute trusts. Providers are operating in the same challenging financial environment as commissioners, which requires providers to deliver a high level of efficiency improvements (largely cost savings) while at the same time making significant improvements in the quality of care. The acute sector faces the greatest degree of challenge as a result of: Ongoing efficiency requirements built into the national tariff of 4.0%-4.5% p.a. The need to meet the LQS which impose minimum service levels necessitating the hiring of additional consultants and other clinical staff Potential loss of income as a result of activity shifts to other settings of care notably as a result of the BCF. Over the five years of the plan there is a collective need for cost savings of 362m across acute providers, equivalent to 24% of the cost base, or average savings of 4.8% p.a.. Based on a substantial body of opinion led by organisations such as Monitor, it is clear that the relatively high level of cost efficiency improvements delivered in recent years by providers cannot be replicated in 19 Sir David Nicholson letter to CCG leaders, Planning for a sustainable NHS: responding to the call to action (10 October 2013) 20 NHS England, Total Allocations (December 2013). 20

23 Chapter 3: Case for Change future years. Monitor s recent guidance has suggested that it considers a modest 2% p.a. savings target is realistic, far below what is required of trusts in south west London. In light of this evidence it must be regarded as highly unlikely that providers will be able individually and collectively to achieve the level of savings and hence financial performance being projected. Accordingly, given the potentially negative impact on local services, commissioners are leading a process of more active planning to deliver a financially sustainable health economy. The dual challenges of achieving the high levels of quality required by clinicians and patients whilst at the same time developing services that are financially sustainable in the long term cannot be tackled individually, it requires a collaborative approach between commissioners and providers. Key driver 4: We need to confront the rising demand for healthcare The demand for healthcare is rising as the population grows and ages. The population in south west London is expected to increase by 7.2% from 1.46 million in 2013 to 1.56 million 21 in The number of people in south west London over 65 years is projected to increase from 178,000 in 2013 to 194,000 in 2018, representing a growth of 8.9% over 5 years. 22 It is expected that more people will be living with multiple long-term conditions (LTCs). The King s Fund reports that for those over 65 years most people have one LTC and for those over 75 most people have two or more. 23 For those living with chronic obstructive pulmonary disease (COPD), data from the World Health Organisation show that death rates are almost double the EU average, 24 and 40% of people with COPD also have heart disease, 25 increasing the complexity of management. Furthermore significant numbers have co-existing depression or an anxiety disorder 26. Studies show that people with LTCs are twice to three times more likely to experience depression and estimates suggest that 20% of people with LTCs have depression. 27 With an increasing number of older people, the number of people living with dementia is also rising. Nationally, there are estimated to be 670,000 living with dementia 28 (although prevalence is lower in south west London than the national average). If someone with dementia is admitted to hospital in south west London they are likely to have a length of stay longer than the national average, and they are more likely to be readmitted to hospital after discharge. People with dementia in south west London are also more likely to die in hospital than the national average 29. Figure 6 presents the local 21 Population Projections Unit, ONS (2012) 22 Population Projections Unit, ONS (2012) 23 Making our health and care system fit for an ageing population, Oliver, D. et al., 2014, London: King s Fund 24 An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England, Department of Health, London: Department of Health, Ibid. 26 Ibid. 27 British Heart Foundation, Twice as likely: putting long term conditions and depression on the agenda, April Dementia: A state of the nation report on dementia care and support in England Department of Health, London: Department of Health, Putting dementia on the map (2013), online resource available from: 21

24 Chapter 3: Case for Change highlights from each of the south west London boroughs from the State of the Nation Report13 which outlines developments nationally since the Prime Minister s Challenge was launched. Between 2009/10 and 2012/13, A&E attendances in south west London s four acute providers increased by 12%. 30 During the same period, the number of A&E attendances for patients aged over 80 years increased by 16% 31 and the number of patients admitted to hospital from emergency departments increased by 12%. 32 The pressure on emergency departments is expected to continue to rise as people live longer with increasingly complex and multiple long term conditions. A&E attendances are projected to grow by 18.8% over the five years of the strategy Population health and inequalities Health inequalities is the term that describes the unjust differences in health, illness and life expectancy experienced by people from different sections of society. The contributing factors to health inequalities are complex and include differences in living conditions, education, employment, diet, levels of smoking, alcohol, exercise, and family/social support networks. However what is clear is that health inequalities are not currently being addressed well enough. The London Health Observatory has shown that Bangladeshi, Black African and Black Caribbean ethnic groups have significantly lower life expectancy than the overall population of the capital. 34 The difference in average life expectancy across south west London is 11 years. People living in parts of Wandsworth and Croydon have a life expectancy of 76 years while in areas of Richmond it increases to 87 years. 35 The NHS cannot alone address all the contributing factors driving inequalities. The single greatest determinant of health status is income and there are significant socio-economic variations in south west London. For example the average income of tax-payers in Richmond, at 56,100, is double the average income of people in Croydon. 36 The most significant impacts the NHS can make on health inequalities are unlikely to be related to big hospitals providing acute and specialised care for very ill people, but from local improvements to community and home-based services being commissioned by CCGs across south west London. There have been improvements across many different areas over the past years and any changes to acute services will be underpinned by continued development and expansion of out of hospital care. Disparity in life expectancy across the south west London boroughs is predominantly accounted for by circulatory and respiratory conditions and cancer. Cancer alone is responsible for up to 32% of 30 A&E attendances statistics by provider 2009/10 and 2012/13, Health and Social Care Information Centre. Note: This includes Epsom hospital. 2012/13 figures include the Croydon Urgent Care centre 31 A&E attendances statistics by provider 2008/09 and 2012/13, Health and Social Care Information Centre. Note: This includes Epsom hospital 32 SUS data 33 Unify activity projections 34 Walters et al (2009) Ethnicity and mortality in London. London Health Observatory 35 Office for National Statistics(2013) Life expectancy by ward ( ) 36 HMRC Survey of personal income: average income of tax payers (March 2010) 22

25 Chapter 3: Case for Change the life expectancy gap. 37 As one of the top three leading causes of death, cancer has a national incidence of 398.1/100,000 population. 38 Across south west London, the incidence is lower than this national average with a higher average one-year survival rate of 69.2% (national one-year survival rate 67.7%) Local performance against the seven measurable outcomes The local NHS has delivered many significant achievements over the past ten years, however there are many areas in which care can be improved. NHS England s seven outcome measures provide a way of assessing our current performance and highlighting the areas which need to be addressed by the five-year strategic plan: The seven measurable outcomes 1 Securing additional years of life for the people of England with treatable mental and physical health conditions 2 Improving the health related quality of life of the 15million+ people with one or more long-term condition, including mental health conditions 3 Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital 4 Increasing the proportion of older people living independently at home following discharge from hospital 5 Increasing the number of people with mental and physical health conditions having a positive experience of hospital care 6 Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital, in general practice and in the community 7 Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care We know that quality of care varies depending on where and when patients access services. There are unacceptable variations, highlighted through performance against the LQS, in the amount of consultant cover available at different hospitals across south west London. Too many people are staying in hospital for longer than they need to because of the lack of appropriate services in the community, and when they are discharged not enough people can live independently in their own homes. We need to improve the quality of life and not just the quality of care for our population. This means working with local authorities and NHS England to ensure equity of access to public health programmes for screening and immunisations, and ensuring that those with long-term conditions are able to better manage their own diseases and continue to live a full life for longer than they 37 Segmenting life expectancy gaps by cause of death, Public Health England 38 Cancer Research UK Croydon CCG&location-1=07V 39 Cancer Research UK 23

26 Chapter 3: Case for Change could in the past. Patients with mental health conditions often have physical health problems as well but have traditionally received less good care and this is not acceptable. The following sections address each of NHS England s outcomes in turn, and highlight current trends in south west London and the priorities which the five-year strategic plan needs to address. Outcome 1: Securing additional years of life for the people of England with treatable mental and physical health conditions People are living longer than ever and with longer life comes an increased likelihood of developing long-term medical conditions, be they mental or physical. This has a knock-on effect of putting further pressure on an already stretched healthcare service. Securing additional years of good quality life for those with such conditions is a priority for modern healthcare and will need to be tackled in a number of ways. Whilst life expectancy overall is increasing, there is a disparity between the most and least deprived areas within individual CCGs in south west London and this will need to be addressed in order to improve overall mortality rates. Tackling lifestyle issues such as smoking and obesity, particularly in the more deprived areas will help, as will improving long term management of health conditions particularly in the community, hence avoiding hospital admissions. Improving access to screening will enable earlier detection and treatment leading to better outcomes for patients. Screening improves outcomes for breast, cervical and bowel cancer and for people with diabetes, screening significantly reduces risk of sight-threatening retinopathy. The screening programme for abdominal aortic aneurysm reduces premature mortality for men and the antenatal and newborn programme improve health and life chances for children and families. We will collaborate with NHS England to ensure we get best value for the population, co-commissioning where this will deliver best value for money. 1.1 Population and life expectancy data for south west London There are now around 1.45 million people living in south west London and our population is growing at one of the fastest rates of any region in England. Birth rates are increasing - on average there have been an additional 541 births each year since and by 2018 the population is projected to increase by 7% and reach 1.56 million 41. The number of children expected to be living in south west London is expected to have risen by 13,500 between 2011 and Both the absolute numbers and the proportion of older people are expected to grow markedly. In south west London the over 65s are projected to increase by 13% by This age group is the most intensive user of health and social care. 43 Nearly two-thirds of people admitted to hospital are over 65 years old - accounting for nearly 70% of hospital emergency bed days Office for National Statistics(2013) Live births by local authority of usual residence by mother, general fertility rates and total fertility rates 41 Office for National Statistics(2012) Interim 2011-based subnational population projections for England 42 Children s Clinical Working Group, Final Clinical Report, March 2013, pg Office for National Statistics(2012) Interim 2011-based subnational population projections for England 44 Kings Fund (2013) Older people and emergency bed use: exploring variation 24